Overview

When you have tried medication, lifestyle changes and other non-surgical treatments but still don’t have relief from your symptoms, surgery is the accepted treatment for a broad range of conditions.

While surgery is generally the most effective treatment option for a range of abdominal and other conditions, traditional open surgery with a large incision has its drawbacks – pain, trauma, a long recovery time and a risk of infection.

As a result, surgery can be a scary proposition for a patient, no matter how routine the procedure. If surgery is recommended, you want to learn as much as you can about your surgical options — including minimally invasive options — and find the physician and hospital that are right for you.

Fortunately, alternatives to a large open incision are now available to more patients facing surgery. The most common of these is laparoscopic surgery, in which smaller incisions are used. While laparoscopy is effective for many routine procedures, it has inherent limitations when more intricate and complex surgery is required.

Thanks to the latest evolution in surgical technology, physicians now have an effective alternative to traditional open surgery and laparoscopy that may allow them to provide more of their patients with the best of both approaches.

With the assistance of the da Vinci ® Surgical System, surgeons can now operate using only 1-2 cm incisions, and with greater precision and control than ever before. da Vinci can help surgeons minimize the pain and risk associated with surgery while increasing the likelihood of a fast recovery and excellent clinical outcomes. And with da Vinci, they can provide these benefits to more of their patients than ever before. 1,2

1. Jacobsen G, Berger R, Horgan S. The role of robotic surgery in morbid obesity. J Laparoendosc Adv Surg Tech A. 2003 Aug;13(4):279-83.
2. Snyder BE, Wilson T, Scarborough T, Yu S, Wilson EB. Lowering gastrointestinal leak rates: a comparative analysis of robotic and laparoscopic gastric bypass.J Robotic Surg. 2008.

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Colon cancer treatment

Most patients with colon cancer are treated with surgery. Some people have both surgery and chemotherapy. Some with advanced disease get biological therapy.

A colostomy is seldom needed for people with colon cancer.

Although radiation therapy is rarely used to treat colon cancer, sometimes it is used to relieve pain and other symptoms.

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Rectal Cancer:

Treatment Overview

For all stages of rectal cancer, surgery is the most common treatment. Some patients receive surgery, radiation therapy, and chemotherapy. Some with advanced disease get biological therapy.

About 1 out of 8 people with rectal cancer needs a permanent colostomy.

Radiation therapy may be used before and after surgery. Some people have radiation therapy before surgery to shrink the tumor, and some have it after surgery to kill cancer cells that may remain in the area. At some hospitals, patients may have radiation therapy during surgery. People also may have radiation therapy to relieve pain and other problems caused by the cancer.

Deciding on Treatment

Many people with colorectal cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask your doctor. It often helps to make a list of questions before an appointment.

To help remember what your doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to your doctor — to take part in the discussion, to take notes, or just to listen.

You do not need to ask all your questions at once. You will have other chances to ask your doctor or nurse to explain things that are not clear and to ask for more details.

Your doctor may refer you to a specialist who has experience treating colorectal cancer, or you may ask for a referral. Specialists who treat colorectal cancer include gastroenterologists (doctors who specialize in diseases of the digestive system), surgeons , medical oncologists , and radiation oncologists . You may have a team of doctors.

Getting a Second Opinion

Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it.

It may take some time and effort to gather medical records and arrange to see another doctor. Usually it is not a problem to take several weeks to get a second opinion. In most cases, the delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Sometimes people with colorectal cancer need treatment right away.

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Treatment Methods

The choice of treatment depends mainly on the location of the tumor in the colon or rectum and the stage of the disease. Treatment for colorectal cancer may involve surgery , chemotherapy , biological therapy or radiation therapy . Some people have a combination of treatments. These treatments are described below .

Colon cancer sometimes is treated differently from rectal cancer. Treatments for colon and rectal cancer are described separately below .

Your doctor can describe your treatment choices and the expected results. You and your doctor can work together to develop a treatment plan that meets your needs.

Cancer treatment is either local therapy or systemic therapy :

Local therapy: Surgery and radiation therapy are local therapies. They remove or destroy cancer in or near the colon or rectum. When colorectal cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
Systemic therapy: Chemotherapy and biological therapy are systemic therapies. The drugs enter the bloodstream and destroy or control cancer throughout the body.

Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each person, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

You may want to ask your doctor these questions before treatment begins:

What is the stage of the disease? Has the cancer spread?
What are my treatment choices? Which do you suggest for me? Will I have more than one kind of treatment?
What are the expected benefits of each kind of treatment?
What are the risks and possible side effects of each treatment? How can the side effects be managed?
What can I do to prepare for treatment?
How will treatment affect my normal activities? Am I likely to have urinary problems? What about bowel problems, such as diarrhea or rectal bleeding? Will treatment affect my sex life?
What will the treatment cost? Is this treatment covered by my insurance plan?

Surgery

Surgery is the most common treatment for colorectal cancer.

A small malignant polyp may be removed from your colon or upper rectum with a colonoscope. Some small tumors in the lower rectum can be removed through your anus without a colonoscope. This is called colonoscopy.

Early colon cancer may be removed with the aid of a thin, lighted tube (a laparoscope ). Three or four tiny cuts are made into your abdomen. The surgeon sees inside your abdomen with the laparoscope. The tumor and part of the healthy colon are removed. Nearby lymph nodes also may be removed. The surgeon checks the rest of your intestine and your liver to see if the cancer has spread. This procedure is called laparoscopy.

Robotic -assisted ( da Vinci ) laparoscopy may also be available. This approach uses a robotic surgical system that provides surgeons with much better vision, precision and control than traditional laparoscopy.

An open approach using a large incision is used most commonly for colorectal cancer surgery. 2 In open surgery, the surgeon makes a large cut into your abdomen to remove the tumor and part of the healthy colon or rectum. Some nearby lymph nodes are also removed. The surgeon checks the rest of your intestine and your liver to see if the cancer has spread.

When a section of your colon or rectum is removed, the surgeon can usually reconnect the healthy parts. However, sometimes reconnection is not possible. In this case, the surgeon creates a new path for waste to leave your body. The surgeon makes an opening ( stoma ) in the wall of the abdomen, connects the upper end of the intestine to the stoma, and closes the other end. The operation to create the stoma is called a colostomy . A flat bag fits over the stoma to collect waste, and a special adhesive holds it in place.

For most people, the stoma is temporary. It is needed only until the colon or rectum heals from surgery. After healing takes place, the surgeon reconnects the parts of the intestine and closes the stoma. Some people, especially those with a tumor in the lower rectum, need a permanent stoma.

People who have a colostomy may have irritation of the skin around the stoma. Your doctor, your nurse, or an enterostomal therapist can teach you how to clean the area and prevent irritation and infection. The ” Rehabilitation ” section has more information about how people learn to care for a stoma.

The time it takes to heal after surgery is different for each person. You may be uncomfortable for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

It is common to feel tired or weak for a while. Also, surgery sometimes causes constipation or diarrhea. Your health care team monitors you for signs of bleeding, infection, or other problems requiring immediate treatment.

You may want to ask your doctor these questions before having surgery:

What kind of operation do you recommend for me?
Do I need any lymph nodes removed? Will other tissues be removed? Why?
What are the risks of surgery? Will I have any lasting side effects?
Will I need a colostomy? If so, will the stoma be permanent?
How will I feel after the operation?
If I have pain, how will it be controlled?
How long will I be in the hospital?
When can I get back to my normal activities?

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. The drugs enter the bloodstream and can affect cancer cells all over the body.

Anticancer drugs are usually given through a vein, but some may be given by mouth. You may be treated in an outpatient part of the hospital, at the doctor’s office, or at home. Rarely, a hospital stay may be needed.

The side effects of chemotherapy depend mainly on the specific drugs and the dose. The drugs can harm normal cells that divide rapidly:
Blood cells : These cells fight infection, help blood to clot, and carry oxygen to all parts of your body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired.
Cells in hair roots : Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
Cells that line the digestive tract : Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

Chemotherapy for colorectal cancer can cause the skin on the palms of the hands and bottoms of the feet to become red and painful. The skin may peel off.

Your health care team can suggest ways to control many of these side effects. Most side effects usually go away after treatment ends.

You may find it helpful to read NCI’s booklet Chemotherapy and You: A Guide to Self-Help During Cancer Treatment .

Biological Therapy

Some people with colorectal cancer that has spread receive a monoclonal antibody , a type of biological therapy. The monoclonal antibodies bind to colorectal cancer cells. They interfere with cancer cell growth and the spread of cancer. People receive monoclonal antibodies through a vein at the doctor’s office, hospital, or clinic. Some people receive chemotherapy at the same time.

During treatment, your health care team will watch for signs of problems. Some people get medicine to prevent a possible allergic reaction. The side effects depend mainly on the monoclonal antibody used. Side effects may include rash, fever, abdominal pain, vomiting, diarrhea, blood pressure changes, bleeding, or breathing problems. Side effects usually become milder after the first treatment.

You may find it helpful to read NCI’s booklet Biological Therapy: Treatments That Use Your Immune System to Fight Cancer .

You may want to ask your doctor these questions before having chemotherapy or biological therapy:

What drugs will I have? What will they do?
When will treatment start? When will it end? How often will I have treatments?
Where will I go for treatment? Will I be able to drive home afterward?
What can I do to take care of myself during treatment?
How will we know the treatment is working?
Which side effects should I tell you about?
Will there be long-term effects?

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cancer cells only in the treated area.

Doctors use different types of radiation therapy to treat cancer. Sometimes people receive two types:
External radiation : The radiation comes from a machine. The most common type of machine used for radiation therapy is called a linear accelerator . Most patients go to the hospital or clinic for their treatment, generally 5 days a week for several weeks.
Internal radiation (implant radiation or brachytherapy ) : The radiation comes from radioactive material placed in thin tubes put directly into or near the tumor. The patient stays in the hospital, and the implants generally remain in place for several days. Usually they are removed before the patient goes home.

Intraoperative radiation therapy (IORT): In some cases, radiation is given during surgery.

Side effects depend mainly on the amount of radiation given and the part of your body that is treated. Radiation therapy to your abdomen and pelvis may cause nausea, vomiting, diarrhea, bloody stools, or urgent bowel movements. It also may cause urinary problems, such as being unable to stop the flow of urine from the bladder. In addition, your skin in the treated area may become red, dry, and tender. The skin near the anus is especially sensitive.

You are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, your doctor can usually treat or control them. Also, side effects usually go away after treatment ends.

You may find it helpful to read NCI’s booklet Radiation Therapy and You: A Guide to Self-Help During Cancer Treatment.

You may want to ask your doctor these questions about radiation therapy:

  • Why do I need this treatment?
  • When will the treatments begin? When will they end?
  • How will I feel during treatment?
  • How will we know if the radiation treatment is working?
  • What can I do to take care of myself during treatment?
  • Can I continue my normal activities?
  • Are there any lasting effects?

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Colorectal Surgery Treatment

Colorectal Surgery

Surgery is a common treatment for a range of benign conditions and cancers affecting either the colon – also called the large intestine or large bowel – or rectum. A colorectal procedure called large bowel resection is used to treat many of these conditions. Large bowel resection (colon resection) is surgery to remove all or part of your large bowel (colon). The digestive track is then reconnected by a technique called an intestinal anastomosis. This surgery is also called colectomy.

Removal of the entire colon and rectum is called a proctocolectomy.

More procedures in this category of surgery include ascending colectomy; descending colectomy; transverse colectomy; right hemicolectomy; left hemicolectomy; low anterior resection; sigmoid colectomy; subtotal colectomy; colon resection; partial colectomy and perineal resection.

The goal of large bowel resection and other colorectal procedures is to treat the condition while preserving normal bowel function. Some of the conditions that may be treated with large bowel resection or colectomy are: 1

  • Colon cancer
  • Diverticular disease (disease of the large bowel)
  • A block in the intestine due to scar tissue
  • Other reasons to perform bowel resection are:
  • Crohn’s disease2
  • Ulcerative colitis
  • Injuries that damage the large bowel
  • Precancerous polyps (nodes)
  • Familial polyposis (an inherited condition in which numerous pre-cancerous polyps form) 3

Surgery for Ulcerative Colitis

Surgery to remove the colon will cure ulcerative colitis and removes the threat of colon cancer. Patients may need an ostomy (a surgical opening in the abdominal wall), or a procedure that connects the small intestine to the anus to help the patient gain more normal bowel function. 4

Surgery is usually reserved for patients who have colitis (inflammation of the colon) that does not respond to complete medical therapy, or patients who have serious complications such as: 4

Rupture (perforation) of the colon
Severe bleeding (hemorrhage)
Toxic megacolon ( acute, severe inflammation of the colonic wall accompanied by stretching that can lead to perforation)

Surgery for Crohn’s Disease

If medicines do not work, bowel resection may be needed to treat Crohn’s disease. Surgery may be used to remove a damaged or diseased part of the intestine or to drain an abscess. A procedure called anastomosis is done to connect the remaining two ends of the bowel. 2

According to the Crohn’s and Colitis Foundation of America, two-thirds to three-quarters of patients with Crohn’s disease will need bowel surgery at some time. However, unlike ulcerative colitis , surgically removing the diseased portion of the intestine does not cure the condition. 2

Patients who have Crohn’s disease that does not respond to medications may need surgery, especially when there are complications such as: 2

  • Bleeding (hemorrhage)
  • Fistulas
  • Infections (abscesses)
  • Narrowing (strictures)

Some patients may need surgery to remove the entire large intestine (colon), with or without the rectum.

Surgery for Diverticulitis

While acute diverticulitis is treated primarily with antibiotics, the affected portion of the colon may need to be removed with surgery if you have any of the following symptoms: 5

  • Abscess
  • Hole (perforation) in the colon
  • Fistula (abnormal connections between different parts of the colon or the colon and another body area)
  • Repeated attacks of diverticulitis

After the acute infection has been treated, eating high-fiber foods and using bulk additives such as psyllium may help reduce the risk of diverticulitis or other symptoms.5

Cancer Surgery

Colorectal cancer requires surgery in nearly all cases for complete cure. 6 Radiation and chemotherapy are sometimes used in addition to surgery.6

Between 80-90% of patients are restored to normal health if the cancer is detected and treated in the earliest stages. 6 The cure rate drops to 50% or less when diagnosed in the later stages.6

Thanks to modern technology, less than 5% of all colorectal cancer patients require a colostomy, the surgical construction of an artificial excretory opening from the colon.6

Depending on the type/location of your cancer, you may have one of the following types of colorectal surgical procedures:

Resections for Colon Cancer
Right/Left Hemicolectomy Resection: Removal of the ascending (right) colon and the descending (left) colon, respectively.
Sigmoid Resection (Sigmoidectomy): Resection of the sigmoid colon, sometimes including part/all of the rectum.

Resections for Rectal Cancer
Low Anterior Resection: The tumor is removed without affecting the anus; the colon is attached to the anus and waste leaves the body in the usual way.
Abdominal Perineal Resection: Removal of the anus , the rectum and part of the sigmoid colon along with the associated lymph nodes , through incisions made in the abdomen and perineum . The end of the remaining sigmoid colon is brought out permanently as an opening, called a stoma , on the surface of the abdomen.

Surgical Options

Today, the vast majority of colorectal procedures are still performed via a large abdominal incision which often extends from the pubic bone to just below the sternum. Open colorectal surgery can be quite painful, involving an increased risk of complications including infection and requiring an extended hospital stay.7

A recent study found that between 2003 and 2004, less than four percent of colorectal surgery in the U.S. was performed using minimally invasive technique. The study of the largest all-payer inpatient-care database in the United States comparing open and laparoscopic (minimally invasive) colorectal surgery found that laparoscopic surgery was associated with a lower rate of complications as compared with open resection (18% vs 22%); a shorter length of stay (6 vs 7.6 days); a reduced need for skilled care after surgery (5% vs 11%), and a lower mortality rate (0.6% vs 1.4%). 9

Fortunately, there are now more minimally invasive surgical options for colorectal cancer and a range of benign conditions affecting the colon and rectum.

While surgical resection to treat colorectal conditions is a relatively safe procedure, it may not be appropriate or necessary for all individuals and conditions. Always ask your doctor about all treatment options, as well as their risks and benefits.

1. Large bowel resection. http://www.nlm.nih.gov/medlineplus/ency/article/002941.htm
2. Crohn’s disease. http://www.nlm.nih.gov/medlineplus/ency/article/000249.htm#Symptoms
3. http://en.wikipedia.org/wiki/Familial_adenomatous_polyposis
4. Ulcerative colitis. http://www.nlm.nih.gov/medlineplus/ency/article/000250.htm
5. Diverticulitis. http://www.nlm.nih.gov/medlineplus/ency/article/000257.htm
6. American Society of Colon & Rectal Surgeons. Colorectal Cancer..http://www.fascrs.org/patients/conditions/colorectal_cancer/
7. Roxanne Nelson. Laparoscopic Colorectal Surgery May Improve Outcomes in Some Patients. Medscape Today. June 28, 2007. http://www.medscape.com/viewarticle/558988

da Vinci® Low Anterior Resection

If you have been told you need surgery for a colorectal condition, ask your doctor if you are a candidate for a very effective minimally invasive procedure – da Vinci® Surgery.

da Vinci Surgery for colorectal cancer and benign conditions uses state-of-the-art technology to help your doctor perform a more precise operation than conventional instrumentation allows.

For most patients, da Vinci Surgery offers numerous benefits over open surgery including:

  • Better clinical outcomes for cancer control in many cases1
  • Quicker return to bowel function1
  • Quicker return to a normal diet1
  • Significantly less pain
  • Less blood loss
  • Less risk of wound infection
  • Shorter hospital stay 1
  • Shorter recovery time1

This procedure is performed using the da Vinci ®Surgical System , a breakthrough surgical platform which enables surgeons to operate with unmatched precision, dexterity and control. By overcoming the limitations of both traditional open and laparoscopic surgery, da Vinci offers patients surgery that is less invasive, more precise and provides a faster recovery.

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1. Hellan M, Anderson C, Blenhom JD, Paz B, Pigazzi A. Short-Term Outcomes After Robotic-Assisted Total Mesorectal Excision for Rectal Cancer. Annals of Surgical Oncology. 200710;1245

While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.